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Table 4

Evaluation of AHRQ's Pharmaceutical Outcomes Portfolio

Table 4: Level 1 Findings: Medication Errors

CERTPopulationFindings
AlabamaGout patientsResults of studying MEDMARX gout medication suggest that inappropriate prescribing practices are characteristic of errors occurring with the use of allopurinol and colchicines. Physician prescribing practices are a potential target for quality improvement.
AlabamaGeneral populationErrors in which the medication reaches the patient but does not cause harm account for the majority of errors reported. Distractions were noted as the number one contributing factor to the error. MEDMARX
UNCPediatricLeading types of errors reported through MEDMARX were omission errors, improper dose/quantity, and wrong time. Consistently, the leading causes of errors seen in pediatric medication errors are performance deficit, procedure/protocol not being followed, and communication.
HMOGeneral populationError rates varied by medication class... for each medication, rates of laboratory monitoring errors were higher among patients with less comorbidity. Over one-fourth of patients dispensing allopurinol did not have serum creatinine monitor during one year of therapy. Lack of monitoring and lack of subsequent possible dosage adjustment puts patients at an increased risk of allopurinol toxicity. Increasing hepatic aminotransferase and thyroid function testing in outpatients prescribed amiodarone could translate into fewer amiodarone-associated adverse effects. A substantial proportion of patients receiving drugs associated with toxicity if concentrations are elevated did not have concentration monitoring during one year of use. Patients with spironolactone therapy and those at risk of hyperkalemia are generally monitored, but there are still many who remain unmonitored.
HMOPhysicians & General populationFindings suggest that patients are not likely to forgive a physician in circumstances where they suspect incompetence, inattention, or a lack of caring on the part of the physician involved.
HMOPhysicians & General populationPatients will respond more favorably to physicians who fully disclose medical errors than to physicians who are less forthright, but the specifics of the case and the severity of the clinical outcome also affect patients' responses.
HMOElderlyRecent rates of potentially inappropriate medication use by elderly HMO members were at least as great as in a 1996 national sample.

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Current as of December 2007
Internet Citation: Table 4: Evaluation of AHRQ's Pharmaceutical Outcomes Portfolio. December 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/pharmportfolio/table4.html